Experiences with an integrated screening programme targeted at women who had a hypertensive disorder or diabetes in pregnancy in the Netherlands: a qualitative study.

OBJECTIVES: Pregnancy is a predictor of women's health later in life. The risk of eventually developing cardiovascular disease (CVD) and/or type 2 diabetes (T2D) increases three to seven times, after pre-eclampsia, hypertension gravidarum or gestational diabetes. The Heart for Women in The Hague project was designed to offer targeted screening to this high-risk population. This research aimed to gather insight regarding the initial experiences of healthcare providers and women with pre-eclampsia, hypertension gravidarum or gestational diabetes. DESIGN AND SETTING: This study applied a qualitative semistructured interview design using an interview guide based on 'The Consolidated Framework for Implementation Research (CFIR).' Interviews were recorded, transcribed and coded in accordance with the five main CFIR themes. The setting of the study was primary and secondary care in The Hague, the Netherlands. Interviews were carried out from December 2021 until February 2022. The language was Dutch or English. PARTICIPANTS: Participants (n=13) were women of the target population (n=7) and relevant healthcare professionals (n=6). RESULTS: Healthcare providers and women were generally positive concerning screening. Healthcare providers agreed that this forgotten group deserves attention and felt that the regional transmural agreement (RTA) provided a clear policy. Women stated that they would like screening to continue and were open-minded regarding lifestyle guidance. Reported barriers included current lack of an easy way of contacting the population after a year, lack of knowledge among the women concerning increased risk, unfamiliarity of new colleagues with the RTA and lack of evidence that screening actually prevents disease. CONCLUSION: Implementation of screening programmes to prevent or delay the development of CVD and/or T2D after complicated pregnancies will likely improve awareness in both patients and healthcare providers. Healthcare providers considered the RTA important because it concerns a forgotten high-risk population. Future research should focus on the improved effectiveness of tailored interventions to delay or prevent CVD.

Added Predictive Value of Female-Specific Factors and Psychosocial Factors for the Risk of Stroke in Women Under 50.

BACKGROUND AND OBJECTIVES: Female-specific factors and psychosocial factors may be important in the prediction of stroke but are not included in prediction models that are currently used. We investigated whether addition of these factors would improve the performance of prediction models for the risk of stroke in women younger than 50 years. METHODS: We used data from the Stichting Informatievoorziening voor Zorg en Onderzoek, population-based, primary care database of women aged 20-49 years without a history of cardiovascular disease. Analyses were stratified by 10-year age intervals at cohort entry. Cox proportional hazards models to predict stroke risk were developed, including traditional cardiovascular factors, and compared with models that additionally included female-specific and psychosocial factors. We compared the risk models using the c-statistic and slope of the calibration curve at a follow-up of 10 years. We developed an age-specific stroke risk prediction tool that may help communicating the risk of stroke in clinical practice. RESULTS: We included 409,026 women with a total of 3,990,185 person-years of follow-up. Stroke occurred in 2,751 women (incidence rate 6.9 [95% CI 6.6-7.2] per 10,000 person-years). Models with only traditional cardiovascular factors performed poorly to moderately in all age groups: 20-29 years: c-statistic: 0.617 (95% CI 0.592-0.639); 30-39 years: c-statistic: 0.615 (95% CI 0.596-0.634); and 40-49 years: c-statistic: 0.585 (95% CI 0.573-0.597). After adding the female-specific and psychosocial risk factors to the reference models, the model discrimination increased moderately, especially in the age groups 30-39 (Δc-statistic: 0.019) and 40-49 years (Δc-statistic: 0.029) compared with the reference models, respectively. DISCUSSION: The addition of female-specific factors and psychosocial risk factors improves the discriminatory performance of prediction models for stroke in women younger than 50 years.

SCORE2 cardiovascular risk prediction models in an ethnic and socioeconomic diverse population in the Netherlands: an external validation study.

Background: Socioeconomic status and ethnicity are not explicitly incorporated as risk factors in the four SCORE2 cardiovascular disease (CVD) risk models developed for country-wide implementation across Europe (low, moderate, high and very-high model). The aim of this study was to evaluate the performance of the four SCORE2 CVD risk prediction models in an ethnic and socioeconomic diverse population in the Netherlands. Methods: The SCORE2 CVD risk models were externally validated in socioeconomic and ethnic (by country of origin) subgroups, from a population-based cohort in the Netherlands, with GP, hospital and registry data. In total 155,000 individuals, between 40 and 70 years old in the study period from 2007 to 2020 and without previous CVD or diabetes were included. Variables (age, sex, smoking status, blood pressure, cholesterol) and outcome first CVD event (stroke, myocardial infarction, CVD death) were consistent with SCORE2. Findings: 6966 CVD events were observed, versus 5495 events predicted by the CVD low-risk model (intended for use in the Netherlands). Relative underprediction was similar in men and women (observed/predicted (OE-ratio), 1.3 and 1.2 in men and women, respectively). Underprediction was larger in low socioeconomic subgroups of the overall study population (OE-ratio 1.5 and 1.6 in men and women, respectively), and comparable in Dutch and the combined "other ethnicities" low socioeconomic subgroups. Underprediction in the Surinamese subgroup was largest (OE-ratio 1.9, in men and women), particularly in the low socioeconomic Surinamese subgroups (OE-ratio 2.5 and 2.1 in men and women). In the subgroups with underprediction in the low-risk model, the intermediate or high-risk SCORE2 models showed improved OE-ratios. Discrimination showed moderate performance in all subgroups and the four SCORE2 models, with C-statistics between 0.65 and 0.72, similar to the SCORE2 model development study. Interpretation: The SCORE 2 CVD risk model for low-risk countries (as the Netherlands are) was found to underpredict CVD risk, particularly in low socioeconomic and Surinamese ethnic subgroups. Including socioeconomic status and ethnicity as predictors in CVD risk models and implementing CVD risk adjustment within countries is desirable for adequate CVD risk prediction and counselling. Funding: Leiden University Medical Centre and Leiden University.

A methodological framework for evaluating transitions in acute care services in the Netherlands to achieve Triple Aim.

OBJECTIVE: The accessibility of acute care services is currently under pressure, and one way to improve services is better integration. Adequate methodology will be required to provide for a clear and accessible evaluation of the various intervention initiatives. The aim of this paper is to develop and propose a Population Health Management(PHM) methodology framework for evaluation of transitions in acute care services. RESULTS: Our methodological framework is developed from several concepts found in literature, including Triple Aim, integrated care and PHM, and includes continuous monitoring of results at both project and population levels. It is based on a broad view of health rather than focusing on a specific illness and facilitates the evaluation of various intervention initiatives in acute care services in the Netherlands and distinctly explains every step of the evaluation process and can be applied to a heterogeneous group of patients.

Opinions on hypertension care and therapy adherence at the healthcare provider and healthcare system level: a qualitative study in the Hague, Netherlands.

OBJECTIVES: Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood pressure is common despite use of these medications. One explanation is therapy non-adherence. Therapy non-adherence can be addressed at the individual level, the level of the healthcare provider and at the healthcare system level. Since the latter two levels are often overlooked, we wished to explore facilitators and barriers on each of these levels in relation to hypertension care for people with hypertension, with a specific focus on therapy adherence. DESIGN: Qualitative study using focus groups of healthcare providers. Data were analysed using the theoretical domains framework (TDF) and the behaviour change wheel. SETTING AND PARTICIPANTS: Participants were from a highly urbanised city environment (the Hague, Netherlands), and included nine primary care physicians, six practice nurses and five secondary care physicians involved in hypertension care. RESULTS: Nine domains on the TDF were found to be relevant at the healthcare provider level ('knowledge', 'physical, cognitive and interpersonal skills', 'memory, attention and decision processes', 'professional, social role and identity', 'optimism', 'beliefs about consequences', 'intention', 'emotion' and 'social influences') and two domains ('resources' and 'goals') were found to be relevant at the system level. Facilitators for these domains were good interpersonal skills, paying attention to behavioural factors such as medication use, and the belief that treatment improves health outcomes. Barriers were related to time, interdisciplinary collaboration, technical and financial issues, availability of blood pressure devices and education of people with hypertension. CONCLUSIONS: This study highlighted a need for better collaboration between primary and secondary care, for more team-based care including pharmacists and social workers, tools to improve interpersonal skills and more time for patient-healthcare provider communication.

The Value of Merging Medical Data from Ambulance Services and General Practice Cooperatives Using Triple Aim Outcomes.

BACKGROUND: Acute care services are currently overstretched in many high income countries. Overcrowding also plays a major role in acute care in the Netherlands. In a region of the Netherlands, the general practice cooperative (GPC) and ambulance service have begun to integrate their care, and the rapid and complete transfer of information between these two care organisations is now the basis for delivering appropriate care. The primary aim of this mixed-methods study is to evaluate the Netherlands Triage System (NTS) merger project and answering the question: What is the added value of implementing a digital NTS merger in terms of healthcare use and healthcare costs? A secondary question is: What are the experiences of patients and care professionals in different acute healthcare organisations following implementation of the digital NTS merger? METHODS: Patients who made an acute care request during the 12 months before the NTS merge intervention (control period) were compared with matched patients in the 12 months following the start of the NTS merge. Outcomes included difference in healthcare use 30 days after an acute event and patient' and care professional' experiences during the intervention period. To assess healthcare costs, we used reference prices updated to 2021. RESULTS: Compared to patients in the control period, patients in the intervention period were hospitalized less often (52.9% vs 64.4%, p = 0.061) and had fewer emergency department (ED) visits (58.7% vs 69.3%, p = 0.074) in the 30 days following the acute care request. The ED costs were significantly lower during the intervention period compared to the control period (p = 0.042). Furthermore, patients in the intervention period were very satisfied overall with the acute care network (4.63 of 5) and care professionals were fairly satisfied with the cooperation to date (2.73 of 4). CONCLUSION: The Triple Aim for acute care can be met using relatively simple interventions, but medical data merging is a prerequisite for achieving more robust results covering on the various aspects of the Triple Aim. These successes should be communicated so that a common language can be developed that will support the successful further implementation of larger scale initiatives.

The general practitioners perspective regarding registration of persistent somatic symptoms in primary care: a survey.

BACKGROUND: Persistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is historically considered a diagnosis by exclusion or primarily seen as psychological. Besides, registration of PSS in electronic health records (EHR) is unambiguous and possibly does not reflect classification adequately. The present study explores how general practitioners (GPs) currently register PSS, and their view regarding the need for improvements in classification, registration, and consultations. METHOD: Dutch GPs were invited by email to participate in a national cross-sectional online survey. The survey addressed ICPC-codes used by GPs to register PSS, PSS-related terminology added to free text areas, usage of PSS-related syndrome codes, and GPs' need for improvement of PSS classification, registration and care. RESULTS: GPs (n = 259) were most likely to use codes specific to the symptom presented (89.3%). PSS-related terminology in free-text areas was used sparsely. PSS-related syndrome codes were reportedly used by 91.5% of GPs, but this was primarily the case for the code for irritable bowel syndrome. The ambiguous registration of PSS is reported as problematic by 47.9% of GPs. Over 56.7% of GPs reported needing additional training, tools or other support for PSS classification and consultation. GPs also reported needing other referral options and better guidelines. CONCLUSIONS: Registration of PSS in primary care is currently ambiguous. Approximately half of GPs felt a need for more options for registration of PSS and reported a need for further support. In order to improve classification, registration and care for patients with PSS, there is a need for a more appropriate coding scheme and additional training.

Large health disparities in cardiovascular death in men and women, by ethnicity and socioeconomic status in an urban based population cohort.

BACKGROUND: Socioeconomic status and ethnicity are not incorporated as predictors in country-level cardiovascular risk charts on mainland Europe. The aim of this study was to quantify the sex-specific cardiovascular death rates stratified by ethnicity and socioeconomic factors in an urban population in a universal healthcare system. METHODS: Age-standardized death rates (ASDR) were estimated in a dynamic population, aged 45-75 in the city of The Hague, the Netherlands, over the period 2007-2018, using data of Statistics Netherlands. Results were stratified by sex, ethnicity (country of birth) and socioeconomic status (prosperity) and compared with a European cut-off for high-risk countries (ASDR men 225/100,000 and women 175/100,000). FINDINGS: In total, 3073 CVD deaths occurred during 1·76 million person years follow-up. Estimated ASDRs (selected countries of birth) ranged from 126 (95%CI 89-174) in Moroccan men to 379 (95%CI 272-518) in Antillean men, and from 86 (95%CI 50-138) in Moroccan women to 170 (95%CI 142-202) in Surinamese women. ASDRs in the highest and lowest prosperity quintiles were 94 (95%CI 90-98) and 343 (95%CI 334-351) for men, and 43 (95%CI 41-46) and 140 (95%CI 135-145), for women, respectively. INTERPRETATION: In a diverse urban population, large health disparities in cardiovascular ASDRs exists across ethnic and socioeconomic subgroups. Identifying these high-risk subgroups followed by targeted preventive efforts, might provide a basis for improving cardiovascular health equity within communities. Instead of classifying countries as high-risk or low-risk, a shift towards focusing on these subgroups within countries might be needed. FUNDING: Leiden University Medical Center and Leiden University.

Effect of COVID-19 on health system integration in the Netherlands: a mixed-methods study.

OBJECTIVES: Overcrowding in acute care services gives rise to major problems, such as reduced accessibility and delay in treatment. In order to be able to continue providing high-quality health care, it is important that organizations are well integrated at all organizational levels. The objective of this study was to to gain an understanding in which extent cooperation within an urban acute care network in the Netherlands (The Hague) improved because of the COVID-19 crisis. METHODS: Exploratory mixed-methods questionnaire and qualitative interview study. Semistructured interviews with stakeholders in the acute care network at micro (n = 10), meso (n = 9), and macro (n = 3) levels of organization. Thematic analysis took place along the lines of the 6 dimensions of the Rainbow Model of Integrated Care. RESULTS: In this study we identified themes that may act as barriers or facilitators to cooperation: communication, interaction, trust, leadership, interests, distribution of care, and funding. During the crisis many facilitators were identified at clinical, professional, and system level such as clear agreements about work processes, trust in each other's work, and different stakeholders growing closer together. However, at an organizational and communicative level there were many barriers such as interference in each other's work and a lack of clear policies. CONCLUSION: The driving force behind all changes in integration of acute care organizations in an urban context during the COVID-19 crisis seemed to be a great sense of urgency to cooperate in the shared interest of providing the best patient care. We recommend shifting the postcrisis focus from overcoming the crisis to overcoming cooperative challenges.

Gender differences within the barriers to smoking cessation and the preferences for interventions in primary care a qualitative study using focus groups in The Hague, The Netherlands.

OBJECTIVES: This research aimed to provide a deeper insight into the gender-specific barriers to smoking cessation and gender-specific preferences for interventions in primary care, in order to contribute to better aligned cessation care for women. DESIGN: Qualitative study using focus groups. SETTING: Regularly smoking female and male adults were recruited from four different general practices in The Hague (The Netherlands). PARTICIPANTS: A total of 11 women and nine men participated. Participants included were regular smokers with a minimum age of 18 and sufficient command of the Dutch language, who were willing to talk about smoking cessation. Inclusion ended when saturation was reached for both women and men. Participants were selected by means of purposeful sampling, whereby looking at age, educational level and experience with quitting. RESULTS: The main barriers to smoking cessation in women were psychological factors, such as emotion and stress, compared with environmental factors in men. Women indicated they were in need of support and positivity, and both women and men expressed the desire for assistance without judgement. Contrary to men, women were not drawn to restrictions and (dis)incentives. CONCLUSION: When counselling smokers, in women the focus should be on perceived internal problems, as opposed to more external obstacles in men. Contrary to men, female smokers seem to prefer non-coercive interventions, such as a group intervention offering support and positivity. Future research should focus on these gender differences, and how they could improve treatment in primary care.

Effects of Technology Use on Ageing in Place: The iZi Pilots.

In the iZi study in The Hague, use and acceptance of commercially available technology by home-dwelling older citizens was studied, by comparing self-efficacy and perceived physical and mental Quality of Life (QoL)-related parameters on an intervention location of 279 households and a control location of 301 households. Technology adoption was clinically significantly associated with increased perceived physical QoL, as compared with control group, depending on the number of technology interventions that were used. A higher number of adopted technologies was associated with a stronger effect on perceived QoL. We tried to establish a way to measure clinical significance by using mixed methods, combining quantitative and qualitative evaluation and feeding results and feedback of participants directly back into our intervention. In general, this research is promising, since it shows that successful and effective adoption of technology by older people is feasible with commercially available products amongst home-dwelling older citizens. We think this way of working provides a better integration of scientific methods and clinical usability but demands a lot of communication and patience of researchers, citizens, and policymakers. A change in policy on how to target people for this kind of intervention might be warranted.

Understanding people who self-referred in an emergency department with primary care problems during office hours: a qualitative interview study at a Daytime General Practice Cooperative in two hospitals in The Hague, The Netherlands.

OBJECTIVE: To provide insight into the motives for hospital self-referral during office hours and the barriers deterring general practitioner (GP) consultation with a primary care request. SETTING: People who self-referred at a Daytime General Practice Cooperative (GPC) in two hospitals in The Hague, The Netherlands. PARTICIPANTS: A total of 44 people who self-referred were interviewed in two hospitals. The average age of interviewees was 35 years (range 19 months to 83 years), a parent of a young patient was interviewed, but the age of patients is shown here. There were more male patients (66%) than female patients (34%). Patients were recruited using a sampling method after triage. Triage was the responsibility of an emergency department (ED) nurse in one hospital and of a GP in the other. Those excluded from participation included (a) children under the age of 18 years and not accompanied by a parent or legal guardian, (b) foreign patients not resident in the Netherlands, (c) patients unable to communicate in Dutch or English and (d) patients directly referred to the ED after triage by the GP (in one hospital). RESULTS: People who self-referred generally reported several motives for going to the hospital directly. Information and awareness factors played an important role, often related to a lack of information regarding where to go with a medical complaint. Furthermore, many people who self-referred mentioned hospital facilities, convenience and perceived medical necessity as motivational factors. Barriers deterring a visit to the own GP were mainly logistical, including not being registered with a GP, the GP was too far away, poor GP telephone accessibility or a waiting list for an appointment. CONCLUSION: Information and awareness factors contribute to misperceptions among people who self-referred concerning the complaint, the GP and the hospital. As a range of motivational factors are involved, there is no straightforward solution. However, better dissemination of information might alleviate misconceptions and contribute to providing the right care to the right patient in the right setting.

[Doctor, know that your patient has Googled: Internet and reason for medical consultation]. / Dokter, weet dat uw patiënt googelt: Internet en de medische hulpvraag.

The internet is increasingly used as a source of medical information, not only by healthcare professionals but by patients as well. We describe the case of Patient A, a 32-year-old male with symptoms of sinusitis. He found a treatment on the internet and was informed when to consult a general practitioner. We also describe Patient B, a 31-year-old female with symptoms of fatigue after the delivery of her second child. Her search on the internet led to several referrals to a medical specialist due to her conviction that her symptoms were caused by a hormonal imbalance. We conclude that medical information on the internet can support both the doctor and the patient, or it can present an obstacle to proper communication during a consultation. Awareness by medical professionals of the Googling behaviour of their patients may be helpful in detecting the underlying question and worries of the patient.

Selective prevention of cardiometabolic diseases in general practice: attitudes and working methods of male and female general practitioners before and after the introduction of the Prevention Consultation guideline in the Netherlands.

RATIONALE, AIMS AND OBJECTIVES: In 2011 the module cardiometabolic risk of the Prevention Consultation guideline was introduced in the Netherlands in order to prevent cardiometabolic diseases. We aimed to compare attitudes and working methods of Dutch general practitioners (GPs) towards selective prevention of cardiometabolic diseases before and after the introduction of the guideline and to study the effect of GP gender on these attitudes and working methods. METHODS: We compared attitudes and working methods in prevention of cardiometabolic diseases in a cross-sectional survey among Dutch GPs in 2013 to the results of a comparable study performed in 2008. RESULTS: Both in 2008 and 2013 30% responded. In 2013, more GPs reported to actively invite patients for preventive measurements. Thirty per cent of the GPs implemented the module cardiometabolic risk. In 2013, less GPs reported that it is worthwhile to make an effort to detect patients at increased risk for cardiometabolic diseases, and more GPs suggested that prevention may be performed by other stakeholders compared with 2008. Financial support and evidence for prevention programmes were mentioned as main facilitators for prevention. In 2013, more male than female GPs actively invite patients for preventive measurements. CONCLUSIONS: More GPs report active preventive working methods after the introduction of the Prevention Consultation guideline, but only 30% implemented the guideline. More male than female GPs actively invite patients for preventive measurements. Compared with 2008 less GPs think it is worthwhile to make an effort to detect patients at increased risk and more GPs are willing to delegate preventive actions to other health institutions in 2013. As financial support and evidence for prevention are important facilitators for prevention, further research of the effectiveness of the guideline in preventing cardiometabolic diseases is necessary, and political choices have to be made in order to financially facilitate selective prevention in general practice.

Prevention in primary care: facilitators and barriers to transform prevention from a random coincidence to a systematic approach.

RATIONALE, AIMS AND OBJECTIVES: The Dutch general practitioner (GP) plays a substantial role in prevention. At the same time, many GPs hesitate to incorporate large-scale cardiovascular risk management (CVRM) programmes into their daily practice. By exploring facilitators and barriers occurring during the past three decades, we wish to find clues on how to motivate professionals to adopt and implement prevention programmes. METHODS: A witness seminar was organized in September 2011, inviting key figures to discuss the decision-making process of the implementation of systematic prevention programmes in the Netherlands in the past, thereby adding new perspectives on past events. The extensive discussion was fully audiotaped. The transcript was content-analysed. RESULTS: We came across four different transitional stages: (1) the conversion from GPs disputing prevention to the implementation of systematic influenza vaccination; (2) the transition from systematic influenza vaccination to planning CVRM programmes; (3) the transition from planning and piloting CVRM programmes to cancelling the large-scale implementation of the CVRM programme; and (4) the reinforcement of prevention. CONCLUSIONS: The GPs' fear to lose the domain of prevention to other health care professionals and financial and logistical support are the main facilitators for implementing prevention programmes in primary care. The main barriers for implementing prevention are the combination of insecurity about reimbursement and lack of scientific evidence. It appears that the ethical view of GPs that everyone should have the same right to obtain preventive care gradually takes over the inclination to hold on to evidence-based prevention.

Multimorbidity in older women: the negative impact of specific combinations of chronic conditions on self-rated health.

BACKGROUND: Chronic diseases are considered major threats to self-rated health (SRH). In many elderly people multimorbidity is present, in elderly women more than in elderly men. This study aims at establishing the impact of multimorbidity and specific disease combinations on SRH in elderly women. OBJECTIVES: To study the relationship between the number of chronic diseases and SRH and explore possible effects of combinations of chronic conditions on SRH in elderly women. METHODS: Health interview data used for this study originated from the second Dutch National Survey of General Practice, a study with a response rate of 64.5%. From the 12 699 respondents, 315 were females between 70 and 74 years old. RESULTS: Of the women, 87% reported one or more chronic condition. Women without any chronic condition rated their health significantly better than those with one or more chronic conditions. Either severe back pain or severe headache was included in return the most prevalent combinations of two chronic conditions with a significantly higher negative impact on SRH than expected. CONCLUSION: All combinations including severe headache and some combinations including severe back pain and another chronic condition had a significantly more negative impact on SRH than expected in women aged 70-74 years. General practitioners should be alert on severe headache and severe back pain in elderly women to improve proactive the quality of care and thus add to the quality of later years of life.

Does prevention of risk behaviour in primary care require a gender-specific approach? A cross-sectional study.

BACKGROUND: In planning a prevention programme, it is important to know to what extent gender, risk behaviour and GP consultation need to be taken into account. OBJECTIVE: To determine whether gender plays a role in the relation between risk behaviour and use of GP services. METHODS: The data used in this study originate from the Second Dutch National Survey of General Practice of 2000-02. We used respondent interviews in three age groups: 555 respondents aged 18-22; 1005 respondents aged 45-49; and 536 respondents aged 70-74. We studied smoking, alcohol abuse, excessive alcohol intake, use of soft drugs, overweight and insufficient physical exercise in relation to use of primary care and gender. RESULTS: Almost all risk behaviours were more prevalent in men. Of all studied risk behaviours, only smoking was related to yearly GP contact and consultation frequency in relation to gender. Smoking men consulted their GP significantly less frequently than non-smoking men, whereas in women, the opposite was the case. CONCLUSIONS: Both rates of consultation and yearly contact were significantly lower in smoking men than in smoking women. Preventive actions by means of case-finding, therefore, are less attainable in men than in women. This outcome may create a double setback for Dutch men, as smoking is a major cause of lower life expectancy in men. Recent data show that under-representation of men among consulters in general practice and excess of smoking men still exist in the Netherlands. This confirms the actual relevance of our findings although these were obtained 10years ago.

Prevention of coronary heart disease and osteoporosis in women aged 45 to 49 years: a challenging role for general practitioners.

OBJECTIVE: Part of the risks for coronary heart disease (CHD) and osteoporosis in women are established by their lifestyle in the premenopausal period. Therefore, we assessed the risk of women aged 45 to 49 years for CHD and osteoporosis and its relation with socioeconomic status (SES) and access to general practitioners (GPs) to provide clues for prevention. METHODS: The health interview data used for this study originated from the second Dutch National Survey of General Practice, a study with a response rate of 64.5%. We studied SES, risk factors for CHD and osteoporosis, and access to GPs in women aged 45 to 49 years. RESULTS: The data of 571 women aged 45 to 49 years were included. A total of 39% had an increased risk for developing CHD in the next 10 years, and 3% had a high risk. A total of 22% had an increased risk for osteoporosis. We found a significant relation between SES and unhealthy lifestyle. An unhealthy lifestyle led to an increased or high risk for CHD, and a high osteoporosis risk. We did not find a significant relation between SES and GP consultation frequency. CONCLUSIONS: Special attention is required for women with the lowest SES because they have an unhealthier lifestyle than do women with middle or the highest SES. The group of women at higher risk for CHD and osteoporosis consulted their GP with the same frequency as did women at lower risk. The Dutch GP seems to be in an ideal position to play a role in the prevention of CHD and osteoporosis in premenopausal women because access to GPs is not influenced by SES.